pain lecture nociceptic and neuropathic
TRANSCRIPT
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PAIN
(NOCICEPTIC AND NEUROPATHIC)
Yudiyanta
Pain Sub-Dept. of Neurology GMU
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KUNJUNGAN POLIKLINIK SARAF RSS TH 2006
4957 (44%)
2850 (25%)
1731 (15%)
626 (6%) 451 (4%)217 (2%)
498 (4%)
0
1000
2000
3000
4000
5000
6000
Nyeri Stroke Epilepsi Vertigo Parkinson Hipertensi Lain-lain
Atralgia28%
Cefalgia
20%
Neuropati
9%
Myalgia
4%LBP39%
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Defining of Pain
Pain Experience
Pain is a personal, subjective experience that comprises :
Sensory-discriminative, Motivational-affective and Cognitive-evaluative dimensions
Ronald Melzack, Textbook of Pain 4th edition
?????
Catastrophization
An unpleasant sensory andemotional experienceassociated with actual or
potential tissue damage, ordescribed in terms of suchdamage.
International Association for the Study of Pain(IASP) 1994, Kyoto Protocol IASP 2008
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Classification of Pain
Physiologic / nociceptive:1
Pain arising from activation of nociceptors
Caused by mild and short noxious impulses which usually relieved without anymedication or mild analgesics
Example: Pinched, stung by mosquito
Inflammatory:2
Pain caused by injury to body tissues (musculoskeletal, cutaneus or visceral) Example: Pain due to inflammation, limb pain after fracture
Neuropathic:1
Pain arising as a direct consequence of a lesion or disease affecting the somatosensorysystem
Example: DPN, PHN
Psychogenic (functional):3
Pain due to abnormal responsiveness or function of the nervous system withoutneurologic deficit or peripheral abnormality.
Example: Fibromyalgia, irritable bowel syndrome
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fracture /
Postoperative
Ongoing or
impending injury
sprain
Inflamation /
Infection
Infiltrated or compressed
(tumors)
strangulated
(scar tissue)
Muscle Stretch
inflamed (infection )
Type or Category of Pain
3. Psychogenic
clear thatno somatic disorder
is present
1. Nociceptive-
Inflamatorik
Caused by activity
in neural pathwaysin response to potentially
tissue-damaging stimuli
2. Neuropathic
Initiated or caused by
primary lesion or
dysfunction
in the nervous sys.
4. Mixed type
Caused by acombination of both
primary injury or
secondary effects
The Assessment of the Patient with Pain, Steven Richeimer, M.D. Director USC Pain Management, USC Medical Center, Los Angeles, CA, USA, 2007
Myofascial pain
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The Continuum of Pain1
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Dorsal Horn
Dorsal root
ganglion
Peripheral sensory
Nerve fibers
A
A
C
Large
fibers
Small
fibers
There are Two Sensory Afferent Neurons
1. Large myelinated A fibers
Very fast conduction velocity
Respond to innocuous stimuli2. Small myelinated A & C unmyelinated fibers
Slow conduction velocity
Respond to noxious stimuli
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Small-fiber sensory Large-fiber sensory Autonomic
-Burning pain
-Allodinia-Hyperalgesia
-Hyperesthesia
-Paresthesia/dysesthesia
-Lancinating pain
-Loss of pain & temp.sensation
-Foot ulceration
-Loss of visceral pain
-Loss of vibration
-Loss of proprioception-Loss of reflexes
-Slowed NCV
-Heart rate abnormalities
-Postural hypotension-Abnormal sweating
-Gastroparesis
-Neuropathic diarrhea
-Impotence
-Retrograde ejaculation
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Nociceptive afferent fiber
Normal Nerve Impulses Leading to Pain
Noxious
stimuli
Descending
modulation
Ascending
input
Spinal cord
Perceived pain
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Nociception
Spinothalamictract
Peripheral
nerve
Dorsal Horn
Dorsal root
ganglion
Pain
Modulation
Transduction
Ascending
input
Descending
modulation
Peripheral
nociceptors
Trauma
Adapted from Gottschalk A et al.Am Fam Physician. 2001;63:1981, and Kehlet H et al.Anesth Analg. 1993;77:1049.
Perception
Transmission
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Activation
External
Stimuli
Heat
Mechanical
Chemical
VR1
Ca2+
mDEG
P2X3
Generator potentials
action potentials
Voltage gated sodium channels
Pain and auto-sensitization
Woolf & Mitchel, 2001
Transduction
ATP
Na+
Modifikasi Meliala, 2003
ACTION POTENTIALACTION POTENTIAL
KERUSAKAN JARINGAN
INFLAMASI
SSA MI NOS
SENSITISASI
AKTIFASIECT. DISC.
Si-Na+
KORNU DORSALIS
PgB, 5HT, Adenosin
Pengalaman
Kognitif
Behaviour
Psikologik
Inhibisi
desendenOTAK
PAIN NO PAIN
R-NE
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Anger
Fear
Anxiety
Depression
Noxious Stimuli
NOCICEPTIVE
A
B
MELIALA 2004
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What is Inflammatory Pain?
Often classed along with acute pain as nociceptive, refers to the
spontaneous pain and tenderness felt when tissue is inflamed.
Pain caused by injury to body tissues (musculoskeletal, cutaneous or
visceral)
Painful region is typically localized at the site of injury often described as
throbbing, aching or stiffness .
Usually time-limited and resolves when damaged tissue heals (e.g. bone
fractures, burns and bruises)
Can also be chronic (e.g. osteoarthritis, rheumatoid arthritis)
Usually responsive to NSAIDs
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NOCICEPTIVE PAIN
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Prostaglandins produced
in response to tissueinjury; increase
sensitivity of nociceptor
(pain)
Nociceptor then releasessubstance P, which dilates
blood vessels and increases
release of inflammatory
mediators, such as Bradykinin
(redness & heat)
Substance P also promotes
degranulation of mast cells,
which release histamine
(swelling)
2
3
Pain-sensitive tissue
Painful stimulus
Prostaglandin
Substance P
Histamine
Mast cell
Blood
vessel
Bradykinin
Nociceptor
Substance P
2
3
1
Inflammation Tissue
1
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What is Neuropathic pain?
Definition:
Pain arising as a direct consequence of a lesion or disease affecting
the somatosensory NERVE system
Characterized by:
Pain often described as shooting, electric shock-like or burning.
The painful region may not necessarily be the same as the site of
injury.
Almost always a chronic condition (e.g. post herpetic neuralgia, poststroke pain)
Responds poorly to conventional analgesics
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IASP Classifications:Peripheral Neuropathic and Central Neuropathic Pain
Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain 2008;137:473-477.
Neuropathic painPain arising as a direct consequence of
a lesion or disease affecting the
somatosensory system
Peripheral neuropathic painPain arising as a direct consequence of
a lesion or disease affecting the
peripheral somatosensory system
Central neuropathic painPain arising as a direct consequence of
a lesion or disease affecting the
centralsomatosensory system
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Pathophysiology of Neuropathic Pain
NeP
Central mechanisms
Peripheral mechanisms
Peripheral Neuron
hyperexcitability
Loss of
inhibitory controls
Central Neuron
hyperexcitability
(central sensitization)
Abnormal
Discharges
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Peripheral Mechanism (Ectopic Discharges)
Nerve lesion induces hyperactivity due to changes in ion channel function
Ectopic discharges
Nerve lesion
Spinal cord
Nociceptive afferent fiber
Descending
modulation
Ascending
input
Perceived pain
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Central Mechanism (Loss of inhibitory controls)
Loss of descending modulation causes exaggerated pain due to an imbalance
between ascending and descending signals
Nociceptive afferent fiber
Noxious
stimuli
Ascending
input
Spinal cord
Loss of
descending
modulation
Exaggerated pain
perception
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Intact tactile fiber
Central Mechanism (Central sensitization)
After nerve injury, increased input to the dorsal horn can induce central
sensitization Perceived pain
Ascending
input
Descending
modulation
Nerve lesion
Nociceptive afferent fiber
Tactile
stimuli
Perceived pain
(allodynia)
Ascending
input
Descending
modulation
Abnormal discharges induce central sensitization
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Development of Neuropathic Pain
Woolf and Mannion. Lancet 1999;353:1959-64
Neuropathic pain
Spontaneous pa in Stimu lus -evoked pa in
Mechanisms
Metabolic Traumatic
ToxicIschemic
Hereditary
Compression
Infectious
Immune-related
Syndrome
Symptoms
Pathophysiology
Etiology Nerve damage due to:
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The Impact of Neuropathic Pain
Neuropathic pain is widely prevalent & generally affects: 6.9% of people with chronic pain1
Up to 24% of people with diabetes2
Up to 50% of people over 50 who recently had herpes
zoster2
75% of people over 70 who have had herpes zoster3
Approximately 33% of cancer patients4
Approximately 4.5% of individuals over 30 following backinjury5
1. Zussman J, Young L. Clin Interv Aging2008;3(2):241-250.
2. Gauthier A et al. Epidemiol Infect 2009;137(1):38-47.
3. Khoromi et al. Pain 2007;130(1-2):66-75.4. Davis MP, Walsh D.Am J Hosp Palliat Care 2004;21(2):137-142.
5. Meyer-Rosberg K et al. Eur J Pain 2001;5(4):379-389.
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Signs and Symptoms of Neuropathic Pain
Delayed, explosive response to any painful stimulus Hyperpathia2
Increased pain sensitivity e.g. pinprick, cold, heat Hyperalgesia3
Painful in response to a non-nociceptive stimuluse.g. warmth, pressure, stroking
Allodynia3
Stimulus-evoked
symptoms
Abnormal, not unpleasant sensations e.g. tingling Parasthesias2
Abnormal unpleasant sensations
e.g. shooting, lancinating, burning Dysesthesias2
Persistent burning, intermittent shock-like or
lancinating pain Spontaneous pain1
Spontaneous symptoms
Descr ipt ion (example)Sign/Symptom
1. Baron. Clin J Pain. 2000;16:S12-S20.2. Merskey H et al. (Eds) In: Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 1994:209-212.3. Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain 2008;137:473-477
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Hyperalgesia & Allodynia
Gottschalk A et al.Am Fam Physician. 2001;63:1979-84.
Injury
Pain
Intensity
10
8
6
4
2
0
Stimulus Intensity
Normal
Pain
Response
Allodynia
Hyperalgesia
Hyperalgesiaheightened
sense of pain to noxious
stimuli
Allodyniapain resulting
from normally painlessstimuli
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What is the Correlation Between Causes Muscular pain
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What is the Correlation Between Causes, Muscular pain,
Neuro-endocrine (HPA Axis) disorders and Psychological distress
Emotional, Environmental and Genetic Predisposition
Cortex-Limbic System- Hypocampus
Thalamus & Hypothalamus
Pituitary
Adrenal,
Thyroid
Perception
CRH, TRH, GhRH, PRF, GnRH
ACTH, TSH, GH, Prolactine, FCH-LH
Cortisone,Thyroid,
Prolactine, Estrogen, Progesterone
Neuro-hormonal Disfunction
Sympathetic Metabolic
PAIN
Muscle TraumaDorsal Horn
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NE5-HT (K l t l 2002)
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DORSAL HORN
NE5-HT
PAF
Spinal Cord
Periphery
STT
STT
Other
Dorsal
Horn
Neurons
Anterior
Horn
Neurons
25-HT3
mu
5-HTNE
NMDA
AMPA
NK1
Glu
SP
NKA
DorsalHorn
Neuron
2 5-HT1Amu
GABA
A/B
GABA
Inter-
Neuron
5-HT
NE
(Kanzler et al., 2002)
PAF
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PAIN ASSESSMENT
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The 3L Approach to Diagnosis
LISTEN
LOCATE LOOKNervous system
lesion / dysfunction
Sensory abnormalities,
pattern recognition
Patient verbal descriptors,
Q & A
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Pain Assessment Scales
Uni-Dimensional Scale Multi-Dimensional Scale
Only measures pain intensity
Appropriate for acute pain
The most common scale used inoutcome assessment (Analgesic
efficacy)
Both intensity (severity) and
unpleasantness (affective)
Appropriate for chronic pain Research /pathophysiology
Should be used in clinical
outcome assessment
Verbal Rating Scale (VRS)
None, mild, moderate, severe
Numeric Rating Scale (NRS)
Visual Analog Scale (VAS)
Pictorial Scale
McGill Pain Questionnaire (MPQ)
The Brief Pain Inventory (BPI)
The Memorial Pain Assessment Card
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Uni-Dimensional Pain Assessment Scales
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Photographic/Numeric Pain Scale
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Photographic/Numeric Pain Scale
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Multi-Dimensional Pain Assessment Scales
Modified
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Modified
McGill Pain
Questionnaire
71,4% Baik
28,6% Lumayan dan
sedang
(Meliala, 1999)
15 Minutes
Sensorik
Afektif
Evaluatif
Macam2IRN
INS
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Quicker and easier
Well established reliabilityin cancer, arthritis, andAIDs.
Sensory, affective andfunctional status
Useful for treatment
response Takes up to 15 min
Good choice for patientswith progressive disease
Worst
Least
Average
Right Now
Treatment
Relief
General Activity
Mood
Walking ability
Normal work
Relation with other people
Sleep
Enjoyment of life
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Rapid: Sensory and affective Reliable in Cancer patients Validated Pocket
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Patient Pain Diary
Morning Afternoon Evening Bedtime
Pain
Scale
10
5
0 Dose Dose
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ID PAIN : Screening tool to help differentiate
nociceptive from neuropathic pain
Neuropathic pain screening questionnaire
A multicenter study
Patients (N = 586) with non-headache chronic painA secondmulticenter study (N = 384) evaluated reliability and validity.
89-item questionnaire 6 items
ID Pain appeared to accurately indicate the presence of aneuropathic component of pain (c 74,2%)
Portenoy R et al. Curr Med Res Opin. 2006 Aug;22(8):1555-65.
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Mark Yes to the following items that describe your pain over the past week and
No to the ones that do not.
If patients have more than one painful area, they are to consider the one area that is most
relevant to them when answering the ID Pain questions.
Scoring was from1 to 5. If you score 2 or more, you may have nerve pain. Talk to your
doctor. Higher scores are more indicative of pain with a neuropathic component
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Location: Patient or nurse marks drawing
Intensity: Patient rates the pain. Scale Used:
Quality: Use patints words, e.g. prick, ache, burn, sharp, hot etc.
Onset, duration, variations, rhythms (spontaneus or evoked):
Manner of expressing pain:
What relieves the pain?
(Pain Behaviour)
What causes or increases the pain?
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What causes orincreases the pain?
Effect of pain: (Note decreased function, decreased quality of life)
Other comments:
Plan:
Accompanying symptoms (eg nausea)
Sleep
Appetite
Physical activity
Relation with others (eg irritability)
Emotion (eg anger, suicidal, crying)
Consentration
Other
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Current Medications
1. Dosage and pattern of use
2. Effectiveness
3. Drug tolerance
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Physical Examination
The history will often generate a differential diagnosis The physical exam will often lead to the selection of the primary
diagnosis, and occasionally a test will help to confirm thisdiagnosis
1. Mental status exam (facial expression)2. Vital signs
3. Inspection (body position, gait, redness, swelling)
4. Palpation & Musculoskeletal exam (atrophy, location
tenderness to pressure, mass, )5. Neurologic Examination (Sensory, Motor, Autonomic)
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NEUROLOGIC EXAMINATION
Possibility :
spinal cord compression,
nerve root lesions
peripheral nerve lesions
Sensory Exam.: numbness,
allodinia,
hyperalgesia
Motoric: fracture? Deep tendon reflexes
Sacral Reflexes
Di ti T ti
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Diagnostic TestingEx.: Diagnostic Test For Low Back Pain
Modality Accuracy Sensitivity Specivity% Agree with
Surgery
Large of Estimates
Clinical Exam 46-76 0.80 0.82
Radiography 34 - -
Myelography 71-91 0.67-0.95 0.76-0.95
CT or MRI 70-100 0.80-0.95 0.68-0.95
Discography 30 0.83 0.63-0.78
ENMG 78 0.66-0.72 -
Bone scans
Somato-sensory evoked potential testing (SSEP)
Quantitative Sensory Testing (QST)
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Psychological Evaluation
1. Mood disorder (50% chronic pain)2. Somatization
3. Secondary gain
4. Sleep and appetite disturbance
5. Loss of energy and libido6. Impaired concentration
7. Suicidal ideation
8. Impact of the pain on the patient day-to-day activities
work & finances personal relationships
recreational pursuits
CONCLUSIONS
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You are the only one who knows how much pain you are feeling
All patients require pain assessment
it is as essential as the other vital signs!(Helen Greene)
If You Dont Measure It, You Cant Improve It(Field et al, 1997)
CONCLUSIONS
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